American Journal of Health-System Pharmacy最新文献

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Purpose: Pediatric prescribing is often weight and indication specific and has been associated with high rates of error. The aim of this study was to evaluate outpatient β-lactam suspension dosing practices for pediatric upper respiratory tract infections (URIs), to characterize the rate of error and to describe common error types.

Methods: This retrospective cohort study was conducted at a community health system with 2 emergency departments and 20 outpatient family medicine practices. Pediatric patients treated from these settings with oral suspension formulations of amoxicillin, amoxicillin/clavulanate, cefdinir, or cephalexin for streptococcal pharyngitis or otitis media between June 1, 2020, and May 31, 2023, were eligible for inclusion. Doses were evaluated against indication-specific best-practice guidelines and assessed for guideline concordance.

Results: Of the 200 patients evaluated, 100 were treated for streptococcal pharyngitis and 100 were treated for otitis media. Of the prescribed β-lactam doses, 32% were discordant with best-practice guideline recommendations. Dosing errors were more common for pharyngitis than for otitis media (47% vs 17%; P < 0.001). Overdosing was the most frequently observed error in pharyngitis prescriptions (93.6% of errors) and most commonly occurred in patients weighing more than the 20-kg weight associated with the dosing maximum (80.9% of overdosing errors). All patients receiving an inappropriate dose for otitis media were underdosed.

Conclusion: Outpatient pediatric dosing errors for URI indications are common among both emergency medicine and family medicine prescribers. Patients weighing over the weight corresponding to the dosing maximum are at highest risk for error. Antimicrobial stewardship interventions targeting the point of prescribing are urgently needed to provide safe dosing practices for pediatric patients.

Purpose: Despite the effectiveness of antibiotic stewardship programs (ASPs) in improving antibiotic prescribing, these are rarely implemented in clinics serving underserved communities. Our objective was to understand patients' perspectives on the factors that can impact implementation of ASPs and integration of pharmacists in antibiotic prescribing in rural clinics.

Methods: We conducted a survey using both quantitative questions and an open-ended question. To participate, patients had to receive care from a clinic serving low-income or rural communities and provide verbal consent to be included in the study. We analyzed the quantitative component of the data using descriptive statistics. The Pearson correlation coefficient was used to examine the relationship between respondents' knowledge of the prevalence of antibiotic resistance and their attitudes toward ASPs and pharmacist integration in antibiotic prescribing.

Results: Of the 189 respondents who completed a survey, 51.3% were female and 51.3% were Caucasian. In our analysis, over 60% of patients reported knowing their prescribed antibiotics' names, while less than 30% possessed adequate knowledge of the indication and duration of the prescribed antibiotics. There was a positive correlation between knowledge about antibiotic resistance and being comfortable involving pharmacists in antibiotic prescribing (P < 0.01).

Conclusion: Many patients supported pharmacist involvement in antibiotic prescribing. Understanding patients' perceived attitudes will facilitate patient-centered, infrastructure-supported interventions by clinicians to improve antibiotic prescribing in the community.

Purpose: To describe the implementation of human leukocyte antigen (HLA)-related genotype-guided prescribing in Singapore.

Summary: Various HLA alleles have been implicated in drug hypersensitivity syndromes (DHS). These include HLA-B*15:02, which has been associated with carbamazepine-induced Stevens-Johnson syndrome/toxic epidermal necrolysis, HLA-B*58:01, which has been associated with increased risk of severe cutaneous adverse reactions with allopurinol use, and HLA-B*57:01, which has been associated with increased risk of hypersensitivity reactions with abacavir use. Integrating pharmacogenomics into patient care through genotype-guided prescribing potentially optimizes use of these drugs by reducing DHS-related and healthcare costs. We describe the prevalence of HLA-related DHS in Singapore, the cost-effectiveness of genotype-guided prescribing, and local policies and guidelines, as well as the impact of genotype-guided prescribing where available.

Conclusion: HLA-related genotype-guided prescribing has the potential to reduce the incidence of DHS and decrease healthcare costs, as seen in the success with carbamazepine. However, not all genotype-guided prescribing is cost-effective when implemented across the population, as was evident from local studies for allopurinol and abacavir. The cost-effectiveness of such measures may change over time with new data (eg, allele frequencies, test costs, drug prices, genotyping approach) and should be evaluated periodically and locally. Implementation of preemptive pharmacogenomics panel testing as part of routine clinical care may shift the threshold for cost-effectiveness and brings promise of further optimization of pharmacotherapy through precision medicine.

Purpose: There is currently limited data on cross-sensitivity between immunotherapy agents. In this case study, we report a case of severe anaphylaxis to both pembrolizumab and cemiplimab.

Summary: Pembrolizumab (Keytruda) and cemiplimab (Libtayo) are both approved for the treatment of metastatic cutaneous squamous cell carcinoma. Infusion reactions occur rarely with immunotherapy agents. However, if infusion reactions are severe, the treatment should be discontinued, and there is no guidance as to whether another immunotherapy agent may be used. An 87-year-old-male was diagnosed with metastatic cutaneous squamous cell carcinoma expressing a PD-L1 combined positive score of 81%-90%. He was treated with pembrolizumab and, 15 minutes after completion of the first infusion, developed swelling of the eyelids, ears, and tongue in addition to a whole-body rash without pruritus. Due to the severity of the reaction, pembrolizumab was permanently discontinued and the patient was then started on cemiplimab. The patient received a high-dose corticosteroid as premedication before the first infusion of cemiplimab and tolerated the treatment without any adverse effects. However, when the corticosteroid premedication dose was decreased before the second cycle, the patient had a severe infusion reaction to cemiplimab requiring discontinuation.

Conclusion: A patient with metastatic cutaneous squamous cell carcinoma developed a severe hypersensitivity reaction to pembrolizumab and subsequently to cemiplimab, despite premedication.

Purpose: Clinical pharmacists are embedded into the care for patients admitted to internal medicine floors at Cleveland Clinic. The existing practice model utilized by the internal medicine pharmacy team had an uneven distribution of clinical activities among the various pharmacist roles. A study was completed to evaluate a potential adjustment to the pharmacy practice model. The objective of this study was to assess the type and quantity of clinical activities performed by each pharmacist role. These data were then utilized to evaluate the need for redistribution of care activities among the pharmacist roles and to determine the need for additional pharmacist full-time equivalents.

Methods: From January to February 2023, data pertaining to the amount and type of clinical activities completed by the 9 internal medicine pharmacist roles was either manually collected or extracted from the electronic medical record. The data were then utilized to calculate a responsibility score for each role. Descriptive statistics were also calculated to assess the results.

Results: Each pharmacist role cared for an average of 34.4 patients (minimum, 24.4; maximum, 57.7) during the study period. The average responsibility score for each pharmacist role was 309.8 (minimum, 237.5; maximum, 447.8).

Conclusion: On the basis of the data collected during the 4-week study period, a new pharmacy practice model was developed that incorporated 2 additional full-time equivalents. This model balanced patient care responsibilities among the pharmacist roles and moved the practice model from a location-based to a team-based coverage model.

Purpose: This study aimed to establish consensus among a sample of pharmacist clinicians on factors that would make them more or less likely to transition from a position primarily in direct patient care to a management position that included direct reports.

Methods: A 3-round modified Delphi survey was conducted. Pharmacists were selected as panelists to gain further information on the transition from a clinician to a managerial role. Study investigators utilized their professional network of pharmacy leaders nationwide who may have had staff who met the inclusion criteria. Participating pharmacy leaders emailed staff an interest survey, and participant email addresses were collected. During the round 1 survey, 2 open-ended questions were used to identify both positive and negative factors influencing pursuit of a managerial roles and responses were analyzed for factor development. In round 2, factors that met or exceeded a predetermined consensus agreement threshold of 70% were included in the round 3 survey. In round 3, a 4-point Likert scale was utilized for respondents to indicate agreement with each factor remaining.

Results: For each consecutive round, the survey response rate was 63% (96/152), 83% (79/96), and 87% (69/79), respectively. A total of 595 factor terms submitted by panelists in round 1 were consolidated into 30 "more likely" and 27 "less likely" factors by round 3. In round 3, the 70% agreement threshold was met across all factors. One less likely factor regarding workload expectations reached 100% total agreement.

Conclusion: The survey results may assist pharmacy administrative leaders in optimizing transitions to managerial roles by considering clinician perspectives.

Purpose: A case of successful transition from high-dose epoprostenol to high-dose subcutaneous treprostinil for treatment of pulmonary arterial hypertension (PAH) is reported.

Summary: PAH is a chronically progressive disease characterized by pulmonary artery luminal narrowing that causes increased pulmonary artery pressures leading to right ventricular failure. Parenteral prostacyclin analogues, such as epoprostenol and treprostinil, are direct vasodilators and are cornerstones of therapy for patients with severe disease that have been proven to reduce mortality and increase exercise tolerance. These agents must be administered continuously via intravenous or subcutaneous devices and are high-risk medications due to their potent vasodilatory actions. Chronic use of these medications requires constant attention from both providers and patients because of potential complications including central venous catheter infection, thromboembolism, therapy interruptions, and other undesirable consequences. This case report describes management of a 35-year-old male patient on high-dose outpatient intravenous epoprostenol (101 ng/kg/min; dosing weight, 47 kg) for treatment of PAH who was admitted to the hospital with a malfunctioning central venous catheter. Surrounding manipulation of the central catheter, the patient experienced an ischemic stroke that led to cognitive disability resulting in a lack of ability to manage his previously used home infusion device. The patient was successfully transitioned from intravenous epoprostenol to subcutaneous treprostinil (discharge dose, 200 ng/kg/min) over 5 days by infusing both medications simultaneously and adjusting doses based upon patient-reported symptoms.

Conclusion: This successful transition from high-dose epoprostenol to high-dose subcutaneous treprostinil demonstrates the importance in considering patient-specific factors during high-risk medication transitions, the value of a patient-directed flexible prostacyclin transition plan, and the benefit of institutional training and education in ensuring the safe use of parenteral prostacyclin analogues.

Purpose: A population health pharmacy team was developed to improve health and increase reimbursement for patients with value-based care plans. The purpose of this study was to evaluate the impact of pharmacy involvement on care gap closure in Managed Medicaid patients.

Methods: This was a single-center, retrospective cohort study of Managed Medicaid patients seen at outpatient facilities. Patients had a pharmacy risk score (PRS) of 6 or greater and had not achieved the Medicaid quality measures for both glycated hemoglobin (HbA1c) and blood pressure (BP). The intervention group included patients reviewed by pharmacy, compared to a control group of patients not reviewed by pharmacy. The primary outcome was closure of at least one care gap by the end of 2022. Secondary outcomes were the number of each type of gap closed, the frequency at which recommendations were made by pharmacists, and the frequency at which pharmacist recommendations were implemented by providers.

Results: Data were collected for 80 patients for the period from January through October 2022. The primary outcome occurred in 37 (74%) patients in the intervention group and 15 (50%) patients in the control group (odds ratio, 2.85; P = 0.032). The HbA1c gap was closed in 30 (60%) patients in the intervention group and 8 (27%) patients in the control group. The BP gap was closed in 24 (48%) patients in the intervention group and 11 (37%) patients in the control group. The frequency with which recommendations were made by a pharmacist was associated with gap closure (P = 0.012). No significant difference was found based on the frequency at which recommendations were implemented by providers (P = 0.4).

Conclusion: Pharmacy intervention was associated with an almost 3-fold-higher likelihood of closing at least one care gap in Medicaid patients. HbA1c gap closure was achieved more frequently than BP gap closure due to pharmacy involvement. The frequency with which recommendations were made by pharmacy was associated with increased gap closure regardless of the frequency with which these recommendations were implemented by providers.